Psychoanalysis and Psychotherapy

Peter Barham. Forgotten Lunatics of the Great War. New Haven and London: Yale University Press, 2004. Pp. 451 £19.99/$45 ($37.81 fromAmazon.com). Reviewed by Allan Young

Because Peter Barham’s book is so singular, it is easy to misread. Difficulties begin with the title. What does the eye-grabbing phrase, ‘forgotten lunatics’, stand for? The ‘Great War’ in the title would seem to be a clue. Haven’t we been around this block before: the road from ‘shell shock’ to traumatic memory, our current master trope for war-time psychiatric casualties and our privileged peep-hole into the khaki-coloured past? What’s Peter Barham’s angle? Chapter one is no help, ditto for the following three chapters, in which he insists on answering the wrong question. I want to know what ‘forgotten lunatics’ signifies and he insists on writing about who they were. He does a superb job: heaps of extraordinary details about extraordinary lives. But still no ‘what’ question by the end of chapter four; likewise no mention of trauma or traumatic memory. Around page 100, it dawned on me that Barham had indeed addressed the ‘what’ question, on page one and each successive page. My problem had been the accursed peep-hole and master trope, not Barham. The ‘lunatics’ mentioned in the title stands for itself: The book is about British servicemen and ex-servicemen who were given the label ‘lunatic’, ‘moral imbecile’, ‘mental defective’, ‘dement’, ‘war psychotic’, ‘incurable’, dementia praecox, or ‘G.P.I.’ (general paralysis of the insane, tertiary stage of syphilis) in the course of being diagnosed or otherwise classified and regulated by doctors, asylum staff, disability rating boards, etc.

A quarter of the way into the book, I had sorted Barham’s servicemen and former servicemen into five categories. There were neurotics, psychotics, and malingerers; the neurotics and psychotics were further divided into cases attributable to service-connected trauma and cases originating in blighted heredity, self-abuse, congenital defects, and who-knows-what? Barham, it seemed, would be focussing on just two categories: war psychotics with service-connected trauma (‘heroic casualties’) and war psychotics with other etiologies. This would make good sense from the prevailing (2005) clinical point of view (separating war-trauma cases from a hodge-podge of chronic psychotics) and forensic point of view (separating patients into the deserving and undeserving). It was smooth sailing up to this point, except for Barham’s puzzling interest in the ‘undeserving’ category, including ex-servicemen who never reached Europe let alone the trenches, and who had been in and out of mental asylums prior to the war. Why would Barham want to clutter his story with these losers on the outermost periphery, with no proper part of the real story as contemporary psychiatry knows it, the narrative that goes from railway spine to PTSD, from half-baked theories about traumatic neurasthenia to a psychiatric science that empowers researchers to measure the chemical footprint of the misregulated hypothalamic-pituitary-adrenal axis in which they distinguish the true case from its look-alike (but only in the aggregate).

And now, half-way through the book, it had become clear to me that these five neat categories (which seem to make perfectly good sense in the epistemic culture of contemporary trauma psychiatry) were part of the problem: a site of contestation and not a resolution. The distinction that proved most problematic for the movers and doers and patients and families represented in Barham’s book was between the heroic casualties and the others, the question of whether all cases of war psychosis, regardless of etiology, might entitle a former serviceman to asylum status as a ‘service patient’ rather than ‘pauper’. In the post-war period, service patients and pauper patients were increasingly accommodated in the same asylums. Service patients obtained a distinctive lounge suit, small change for smokes and sweets, an improved diet (sometimes), and the possibility of a pension. Sometimes the difference between the two kinds of asylum patients was more symbolic than real. It depended on when and where a service patient found himself. The distinction could have significant material consequences for these men and their families, and they were the subject of intense debate and disagreement among psychiatric authorities and between the Ministries of the Treasury and Pensions.

In 1917, it was decided to eliminate the distinction between cases with and without service-connected trauma, where it could be presumed that military service – even brief and served in Britain – had exacerbated (accelerated, deepened) pre-existing psychiatric conditions, including G.P.I. According to Barham, this decision was a noteworthy event in the evolution of British social democracy. It brought previously discarded people in from the periphery and affirmed their membership in a ‘community of citizens’. They included psychotic men who had made no personal sacrifice on behalf of the nation, whose character deviated diametrically from the prevailing ideals of masculinity (will-power, self-discipline) and patriotism, and whose ‘difficult situations’ were comprised by terrible childhoods, cascading misfortunes, and overwhelming unsuitability for military life rather than trauma in the trenches. Mixed among these unfortunates were war psychotics whose etiological situations consisted of months, sometimes years, of trauma in the trenches. The two kinds of unfortunate situations were by not mutually exclusive of course. And then, there were also malingerers, out to nab pensions.
Socially progressive institutional developments were also taking place during this period, most notably the establishment of a network of humane and innovative residential units for the care of war psychotics. But Barham’s history does not portray an inexorable passage out of darkness (an entrenched medico-military complex opposed to psychological medicine) into light (the social-welfare state). Progressive policies were reversible and revisions in the status and entitlements of war psychotics went on and on, ending with death of the last of the lunatics in the 1960s.

The richness and multiplicity of Barham’s accounts make Forgotten Lunatics of the Great War an absorbing book. But it is also a challenging book, for he refuses to reduce these truly odd men to recognizable (i.e., conventional, self-satisfying) clinical types, just as he refuses to transform moral confusion (then and now) into a redemptive history. Barham does not airbrush portraits of men who were not simply odd and feckless but often difficult, unpleasant, and occasionally even dangerous.

The book includes appreciative accounts of Grafton Eliot Smith and Tom Pears at Maghull Hospital, of Milais Culpin at the same place and then beyond. W.H.R. Rivers, now famous in fact and fiction, in novels and on screen, and briefly at Maghull at the invitation of Eliot Smith, makes a cameo appearance. Craiglockhart Hospital, where Rivers introduced Siegfried Sassoon to a form of self-healing called autognosis, is mentioned only in passing. In their place, Barham gives unsentimental accounts of sadder places, like the Napsbury Military Hospital, and obscure but once important medical men, like Maurice Craig. The war psychotics were generally beyond reach of psychotherapy. According to retrograde authorities, this condition was in itself sufficient for labelling them ‘incurables’ and returning them to the outermost periphery of civil society, to be finally forgotten. Barham argues that this view was mistaken, both morally and medically. Among the war psychotics there were men who experienced ‘spontaneous remissions’ or at least periodic remissions that permitted them to re-enter the everyday life of their communities and families as disabled pensioners. And no liberal society has warrant to discard any of its citizens.

Peter Barham's book is impressively original, fluent, and indispensable for readers, researchers, and clinicians interested in the psychiatric casualties of war past and present.

Allan Young is a social anthropologist in the Department of Social Studies of Medicine and Department of Psychiatry at McGill University. He is the author of The Harmony of Illusions: Inventing PosttraumaticStress Disorder (1995) and is currently engaged in research on psychiatric uses of the social brain and post-genomic mind. He can be reached at the Deptartment of Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal (Qc) H3A 1X1, Canada; and at
allan.young@mcgill.ca